Random thoughts from a few cantankerous American physicians. All contributors are board certified. Various specialties are represented here. I do not know where this will lead but hope it will at least be an enjoyable read. All of the names mentioned in this blog are pseudonyms, the ages have been changed, and in half the cases the gender as well. All photographs are published with patient consent or are digitally altered to preserve anonymity. Trust us, we're doctors.

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Monday, February 18, 2008

Just for fun try to find the 5 year success rates, published, from reputable journals, on the success of our current treatment of ''addiction as a disease''. You probably can't and there's a reason. The success rates are no better than going "cold turkey". It's about 5%. This realization has hit me hard as I have seen about 6 or 7 former addicts recently. None of them had gone through the twelve steps or anything like them. They just quit.

Penn and Teller, on their show "Bullshit" do a great piece on this current snake oil and say the same thing. Now I'm not citing Penn and Teller as authorities on medicine, but I have noticed the "recovering" alcoholics, and addicts of whatever substance or behavior they are addicted to, come out of various twelve-step programs helpless and pitiful. They are told that they have no power over their addiction and that they have to surrender to a 'higher power' which may, in fact, be anything they choose, and if I were doing it my higher power would be Brittney Spears.

I don't think it's a jump then, since you have 'no power' over whatever substance or behaviour you are 'addicted to', to simply cave at the first opportunity and to feel terrible about it and go running back to AA or whomever. The fact of the matter is that unless you want to quit that the twelve step programs are not going to work, I maintain they are harmful and destructive. You are getting something from your substance abuse and unless you figure out how to find it without alcohol or drugs then you are going to cycle down to oblivion and waste an incredible amount of time and money on a treatment that doesn't work. I am in the minority of physicians on this one I know and a whole 'science' of addiction medicine has grown and flourished since addiction has won the moniker of disease.

So what is it? It's the easiest choice for the person involved. It's the quick choice, the quick release, the immediate gratification. It's easier than the problem. Simple as that. So, to look inward and honestly or to look outward to others to fix your problem. It's very modern to choose the latter and certainly not based on reproducible data.

Now I'll sit back and wait for the inundation. Think I'll have a cocktail.

89 comments:

I'm on the social work side of things, ie in contact with addicts before and after they end up in the ER (again, and again).

I'd agree, in that all the treatment systems I have seen have not had very impressive success rates; basically, an addict is going to quit or not, and no amount of programming or therapy can change that. But programs and groups and so on can help one who as actually decided to quit, if in nothing other than keeping people busy and thinking that they are doing something for themselves. The devil finds work for idle hands and all.

In terms of social policy though, the disease model is a hell of a lot better than the criminal/moral failing one, which also have pretty dismal success rates and many perverse consequences. Perhaps a disease model that regards addiction as essentially chronic and untreatable, with a fairly good chance of eventual spontaneous remission if it doesn't go terminal first, is a more productive way of looking at it. Pretty much matches my experience anyway.

Perhaps what you really mean to do is rant against addiction as a treatable disease. Best treatments we can come up with being essentially harm reduction and palliative care really.

rob, i would disagree in a couple of respects. i think the current model DOES NOT help people who have decided to quit any more than that person going cold turkey. that's the statistics.

my other problem with it is that it expands the definition of disease into the realm of choice.

however difficult it is for an addict to refuse a drink or a snort it remains a choice.

calling it a disease removes the element of personal responsibility and i fail to see why the same reasoning can't be applied to all other forms of poor choices that are destructive to the person or those around him or her... criminal behavior for example.

disease means something specific to physicians (most of us anyway), whether it be infection or broken bones or even schizophrenia. to wit, here's the first definition from dictionary.com

I would offer up that really hardcore alcoholics (eg. everyone in my family) have a choice to drink, sure, but at this point, the choice to not drink on any given day includes the choice to have shaking episodes, incontinent stools, possible life-threatening rise in blood pressure, and/or seizures, so the "choice" to not drink should include admission into some sort of detox program.

The choice is more drink or be admitted vs. drink or not drink.

"Choice" is kind of a strong word for these people after they are so physiologically and psychologically dependent. The people who would experience mild non-life-threatening withdrawals are in that "choice" grey area. After you are detoxed THEN it becomes a choice whether to drink again and how frequently.

agreed 100%. in fact, at the mecca where i trained it was a very friedly city for the homeless alcoholics. i made the suggestion, only half joking, that instead of telling all of them when they were discharged to stop drinking we should rather tell them 'never stop drinking'. that way, rather than see them once a week for withdrawal we would see them only when their liver's or pancreases failed and we could actually do something important.

ditto to benzo withdrawal, and any severe withdrawal syndrome. good point. while i would argue that the choice is always there choosing not to drink when you are starting to panic and shake all over might acutally kill you.

It annoys me to no end that character flaws are turned into diseases because it is so much easier to have one's weakness validated by the medical community and all its pseudo-satellites than try to change one's behavior.

I don't think there is much disagreement. As you point out, from a ER point of view, it is an individual choice, and not a disease.

From my point of view, the guy that has to deal with these folks after you discharge them, well, questions of choice don't really enter into it. Nor does character. Unless you are willing to take the view that they actually should die because of their character weakness (hey, how are you on gangbanger GSWs?)

Once out, addicts are going to do it, and my job is to try and keep them alive until they try and stop doing it, die, or see if there is anything I can do to help them if they do make that choice to try and stop (not much, really), which is where I strongly agree with you.

Putting it in the framework of choice is perhaps as misleading as putting thinking of it as a disease model I think: at what point on the continuum does a suicidal patient slide from depressive to stupid (or, given some of their circumstances, actually very rational)? (Boy, am I not ever supposed to say that.)

I'm not looking at it from an immediate medical response point of view, but I suppose as a larger social way of thinking about addictions. It might not be a disease, but in terms of how we as a society can deal with it, it is a far better analogy than criminal sanctions and shunning. Which appear to be the only options on the menu right now.

Me, I think if we had a slightly more rational addictions policy, we could significantly reduce your customer load.

For fun, ask a substance abuse professional why its ok for a narcotics addict to get intravenous narcotics for surgery. They'll give you a song and dance about how narcotics given for true pain don't set off the cravings/disease the same way narcotics used for fun do. You can get 60cc of fentanyl for your CABG and you'll be fine, take a tylenol#3 for fun and you turn to stone.

i think you need to rethink your statement 'once out addicts are going to do it...' this is not always true or everyone who ever drank in college like i did would be dead by now.

i think there exists a small percentage of the 'hopeless' in terms of substance abuse, what i am saying is that the addiction model has given great numbers of people who probably could manage their cravings or quit entirely a devilish excuse to fail and fail again. not only that, the surrendering of their personal responsibility snowballs them into small people. so, in that regard, i would say that criminalization and certain punishment might actually do better than what we have now.

however, i do agree that prohibition is a bad idea and i also agree that there are lots worse things to use than marijuana... alcohol for instance.

our national drug is alcohol, and if i remember correctly you are in Canada so it's yours too.

you choose to analogize to suicide and i would not choose that analogy. i do believe in depression as a disease for reasons that should be clear. i may end up being wrong along with our current neuroscientists and i am of the mind that people have a great deal of control over their depression but the studies about neurotransmitters are quite convincing.

one might analogize to alcoholism and speak of genetic predispositions but the only things i know that are 100% genetically determined are hair color eye color and even those are tricky.

also, in terms of the studies finding elevated or depressed whatever-a-mine of the day i would ask what those levels were when the patient was born and even if it could be shown that these levels correlated to alcoholism in later life then i would ask if these were correlative only of alcoholism and not of depression.

the fact remains that if one believes that all these things are preprogrammed then we really shouldn't speak in terms of right or wrong or good or bad and western civilization as we know it dies.

Several years ago I did an anesthetic pre-op on a gentleman scheduled for a CABG/aortic valve replacement. He told me he was "in recovery", and could not have any form of opiates for his anesthesia. This question had come up before, when patients claimed allergies to opiates, but it was always more of an academic exercise. Thoracotomies require positive pressure ventilation, so an entirely regional approach is out. Theoretically a high spinal or complete spinal would provide sufficient analgesia, although making coming off bypass quite challenging. Intravenous ketamine has the advantages of profound analgesia, amnesia, with minimal cardiovascular effects, but probably not the best choice for a drug fiend. Of course, my attending had the right answer. I pulled the anesthesia record from his hip replacement the previous year. Apparently 15cc of IV fentanyl hadn't turned him in to a drooling Rush Limbaugh, infact, for a procedure with several narcotic free options, he got the standard general anesthetic/opiate combo.

One of the difficulties of both our professions, like the cops' too incidentally, is that we only get to see people when things go wrong. Often really really wrong. Most people, most of the time, do not end up in your care or mine or that of the criminal justice system. The issue is not what is general, but what we have to do with the specifics of what we are presented with.

Perhaps one of the "defining characteristics of Western Civilization as we know it" is how we deal with the kinds of folks that end up under our various gentle ministrations. The folks for whom the whole thing isn't working out so good, Darwinian though it may be.

Me, I'll go with what works, and in my line of work I find pessimism is a better starting point, but then I am a social worker not a doctor, where I hope to god you guys start with an insane level of optimism about my own personal outcomes!

Anyway, being an addict is about as much fun as sitting in an ER waiting room in pain for 9 hours because things are gridlocked or whatever. Nobody would choose that sort of life, outside of the addiction. Addicted life sucks, big time, it isn't like you need a piling on of misery to convince you to quit. Self inflicted misery is most often the cause of turning things around.

In the meantime, you and I, we try and keep them from bleeding out and fed and clothed, and generally speaking, not quite dead yet (a la python), we're on the same team right?

(Oh, and back in the day, I used to bounce, and I used to fervently swear, "please smoke your brains out and don't drink, please, all the weed you want, stay away from the likker. But no, you bounce, you work with liquor, simple as that. Like an ER doctor I imagine.)

yeah, we do what we can. what does 'bounce' mean? unfortunately my optimism has been handily beaten from me and i start from pessimism of a particularly bad form. my point of view is that the likelihood of you dying in front of me is inversely proportional to how big an asshole you are.

Choice, choice, choice. Period. You pansy jackasses. If it's not now, it was at one time. One nation under therapy. Grow some balls and get control. I fear for my children's future. Responsibility, as well. When did that word leave the national lexicon. If you enjoy the drink, coke, smoke, etc. fine. Just don't expect me to clean up your shit.

I believe in personal responsibility. It may be hard, but it is still a choice. I couldn't choose not to have cancer no matter how hard I wished I could because that wasn't a choice.

Have you seen Celebrity Rehab though? If I believed in scaring my kids to make them never try drugs I would make them watch that show. I used to think the guy from Taxi (Jeff Conway?) was hot and now he is just plain scary. It terrifies me that someone could be so out of control. But you know, celebrities seem to not have to have any kind of control over themselves and people are ok with it.

The fear of being out of control is why I never tried any drugs in my life...with the exception of alcohol. I know I told you about my scary blood alcohol level that one time in college, and that was probably the last time I ever got drunk.

I think what I am trying to say in this very long winded comment is that I agree with you.

Hey there! I am a social worker grad student. I intern at the VA with mandated MICA clients. MICA= Mental illness chemically addicted.

I hate the AA model, hate it. I am a harm reduction person. I find that when my mentally ill clients are detoxed (detox should be a medical model, always), and they start dealing or medicating their mental illness....

SURPRISE!!!!

They get better.

I actually have previous crack addicts with pre-diagnosed schizophrenia do really really well. Clean and Sober for years.

As for those that are just addicted without a mental illness? I wish they had methadone clinics (They should have similar treatments for crack and meth) on every block so they stay out of your ER trying to score drugs.

No one will get better until they chose to get better. Being an addict removes you rights to be a custodian to minors, have a license etc...

When someone wants to work on a life not surrounded by an addiction, come see a social worker.

I work at VA that has a very successful MICA treatment rate. Our straight substance abuse program sucks ass...

I have no idea. Watching my mom struggle with alcoholism over the years, I'd say that drinking vs. not drinking may be a choice, but alcoholism certainly seems to be a disease. And though AA smacks of bullshit to many of us who are not addicted, it has worked for my mom -- so I can't complain. She had 7 years' sobriety after a stint in a traditional medical dry-out facility, but it was tenuous and eventually she went back to drinking. Her current AA-assisted sobriety seems much stronger and it's been close to 15 this time.

You could argue that this time maybe she was really committed to the change. Who knows. But if it works for some people, then it's doing good. The others, maybe nothing will work.

pretty ignorant post. Especially from a doctor.I worked in addictions for several years as an addictions counselor and we had to do a lot more than fill them up with fluids, sober 'em up, patch the scrapes up, and send them on their way. Docs just get burned out on addicts because they are hard to deal with in practice and because they get annoying. We had to actually confront the issues and address the disease. This takes more understanding, patience, and theory than the ER docs have.... 12 step treatments do work. AA works. NA works. These people are powerless over their d.o.c....thats why they are ADDICTS.

The reason it is a disease is because it causes destruction. Why is parasite induced destruction called a disease? b/c of incurred damage to the body. If the damage comes from the person herself, why is this destruction not disease? This is a mental disease. Often our addicts were bipolar as well. Or Abused. Or depressed. Addiction being called a disease is no different than other behavioral phenoms like anorexia, bulimia, excessive hair-twirling, whatever. Just because the recovery rate is low (which it is) does not disqualify addiction from the realm of disease. It just makes it a deadly one.I know it is hard working with addicts. Just don't be ignorant because of this fact.

Docs get burned out on addicts because they see too many of 'em, especially in ERs, and the addicts are manipulative, pathologic liars much of the time. I am fortunate to be in primary care, where I have quite a few patients who've kicked bad habits, and I agree that the use of a mind-altering drug is a choice. I am wondering if the edifice of addiction medicine is really about containment, rather than cure; about trying to limit the damage done.

I'd like to see the literature on addiction treatment programs and methods. I believe depression is a disease partly because very good randomized controlled trials showed that a placebo was not as effective for treatment of it as a chemical (anti-depressant). Are there such data for treatment of addictions? Or at least, some good comparative studies. That would be interesting.

Listen...I am a medical student who has 3 practicals and a 5 subject block exam this week so please pardon the grammar and the lack of evidence as I have other things to do besides write perfect responses on your blog.

Sounds like you are sick of addicts in your ER. I get it. I really do. But the fact is, just because you deal with them does not mean you know shit about the subject. I think this article is interesting in the context of this discussion.Abstract:

Affiliation with 12-step groups has been consistently linked to the achievement of abstinence among persons experiencing alcohol and other drug problems. Clinicians play a critical role in fostering clients’ engagement in 12-step, yet, little is known about clinicians’ attitudes and beliefs about 12-step groups, or about the association between such beliefs and referral practices. This exploratory study investigates this association to gain a greater understanding of determinants of referral practices. Participants were 100 clinicians working within outpatient treatment programs in New York City. Participants held highly positive views of 12-step groups in terms of helpfulness to recovery, but a large percentage endorsed items describing potential points of resistance to 12-step groups, in particular the emphasis such groups place on spirituality and powerlessness. More positive attitudes were associated with greater rates of referral, while resistance to the concepts of spirituality/powerlessness was associated with lower rates of referral. Implications of findings for clinical settings are discussed as well as a research agenda designed to more fully elucidate determinants of clinicians’ 12-step referrals.

So....it is proposed that 12 step works (and this is not really something I am going to go out and prove to you tonight) but those that have issues with spirituality and powerlessness won't refer Let me guess, you are not into spiritual care in your approach to medicine either? Probably not referring to AA or NA? Oh…wait they come back to you? Have you considered that your Tx as a doctor is not working? All, I am saying here is that addicts are people with a mental disease that requires treatment like any other disease. Just because they act like asses does not mean you should not put full effort into helping them every time you are able to do so… 12 step is one key element in many tx plans and it forms a support network for those that have none, a spirtual and emotional foundation from which to build, and a historical context of helping many people get sober. In our center, those who did not participate in 12 steps were the ones failing. I think people in our society think 12 step is some 12 day program like the hollywood folks go off to get sober. But they are not: they can help maintain a person's sobriety for years and years.

I like your comment above: "and i start from pessimism of a particularly bad form. my point of view is that the likelihood of you dying in front of me is inversely proportional to how big an asshole you are."

We have a simple dichotomy here:1. the "choice" camp who interestingly have enormous experience with "addiction" and are in a position where they are forced to "treat" the addict: ER docs, Hospitalists (that's me), a few primary care docs, and ED social workers.2. and those who make money (or are religious recruiters) treating the addict.

Professionals of "Addiction Medicine" clearly have a financial interest in calling it a disease. If they agreed that their "patients" (i.e customers) simply made bad choices then they would need to change the title of their profession to "Care for the Weak-minded", or "There is Nothing Really Wrong With You", or simply "Go Cold Turkey"... wait that's called Detox and it's free! It's also where I want to send your suburban lawyer ass when you show up in the ER whining after soiling yourself in your girlfriend's Lexus. Pretty obvious where I work... it ain't inner city.

Wow, I'm having flashbacks. I rememember sitting in my microbiology class watching the pre-med guys duke it out over what the right answer was on a stupid group project. It seriously almost came to blows on more than one occasion.

I love how smart doctors are.

My dad quit smoking cold turkey after years of it. My ear infections as a small child magically went away once he quit.

ummm...LCPCs, social workers, and CACs are the ones who do the real life brunt work with addicts and while the doctors at the top may be the one's defining addiction as a disease, I think the worker bees would agree with them. AND, they have nothing to gain except a crappy 30,000 dollar/yr income. Sidenote: I worked at a "cold turkey" detox as well and guess what? They use 12 step, meditation, and other group meetings there as well. The folks would come back for AA and NA after finishing their physical withdrawal. So "detox" and "12 step" are not separate entities in real life outside your posh ass town.

The best de-bunking of "alcohoism as a disease" was on my beloved South Park.

http://en.wikipedia.org/wiki/Bloody_Mary_%28South_Park%29

I do agree with Nurse K that detox necessitates medical management. You can die from that shit! (Love your blog, K.)

I quit my addiction cold turkey. It sucked. I would literally sob and cry and feel utterly despondent because I wanted to eat. Who knows what feeling I was trying to smother with food? I tried OA, but I cannot abide the bullshit religious undertones. (And fuck yes I was as addicted to binge eating as any crack whore to the pipe.) It wasn't a disease, it was (like living healthily) is a lifestyle CHOICE.

Lets just hand out crutches to people on every street corner. It's not your fault, you can't help it... you have a disease! Waaaaaaaahhh!!

The 12-step program advocates dominate corporation substance abuse pr0grams which are tacked onto the wide spread drug testing in industry.I have worked with them and find almost all to be "recovering" alcoholics.Try and discuss the evidence for the effectiveness of the AA and AA type programs and you will be preached to.The best thing you can do if you are worried bout being fired for poor job performance is to drink enough to get caught and then you are offered salvation and time off to recover and then back to work as a protected handicap worker.

"You are getting something from your substance abuse and unless you figure out how to find it without alcohol or drugs then you are going to cycle down to oblivion and waste an incredible amount of time and money on a treatment that doesn't work."

I think that's the key right there, and I don't think that I've met an addict that didn't apply to.

ladyk73 had a point, treating the underlying mental illness. For some people, an addiction support group provides the therapy for them to address their issues, especially when they need to look at themselves as the source of the problem and why they need *insert drug of choice here* to assist them in coping with general life.

You’re in the trenches, so I’m hardly one to dispute your observations. But I can’t help but ponder your conclusions that AA is harmful and destructive. They create a safe place in which the addicted can come in and unburden their souls. Is that destructive? After all, these folks invariably have a lot of demons. They offer the addicted the buddy system. Is that harmful?

Is it a crutch? Maybe. But if it’s effective in helping slay the addictive dragon, does it matter? It sounds as though AA works off the tenant that the addicted are psychologically weak – hence the “give yourself up to a higher power,” and “it’s not your fault because you’re in the grips of a disease.” I don’t see this as a huge problem because it’s a panacea these folks can latch on to. If it gives them enough strength to quit their drug of choice, is that mindset necessarily bad?

Since the stats between AA and cold turkey are about the same, I see AA as filling a void for those who don’t have the walnuts to go cold turkey. As for the “higher power” bit, I was always under the impression that the higher power they espouse meant God, not a peanut butter and jelly sandwich.

I agree with you that this can play nicely into those who love playing the victim role. But in the end, who cares? There are always going to be “victims” and those who stand on their own two feet. The goal is to be addiction free. If the stats are equal, then where’s the harm in people using a treatment that makes them more comfortable? I know a handful of people who found strength through AA.

I’m not advocating any treatment either way. I think AA has its place, and the end result should be that the addicted GET treatment – whatever form that takes.

No comment from me to say you are crazy. Although I must say you are totally uninformed. Do you know the purpose of the 12 steps? Do you know what powerlessness really means? Do you know that more doctors have killed alcoholics and addicts (Heath Ledger, etc.) THAN TREATMENT OR THE 12 STEPS?

I have known and know people, that you likely wouldn't allow in your office, become healthy productive, tax paying citizens who I am sure you would see as a drag on society in their former lives.

Apparently you don't keep up on the research in your field or you would know about neuro biology work that is being done all over this country, further validating addiction as a disease. I really don't care what addiction is called but I do care about the stigma that recovering peoiple face, and people like you who perpetuate that stigma.

Now let me tell you what powerless really means, it means that a person is powerless over the substance once they ingest it. Thats all it means.

And the purpose of the 12 teps is to take a continuous look inside self to determing exactly what it is that caused us to use in the first place. Just what you suggested is the answer.

I received a DUI and have thus gone through the ringer of (outpatient) alcohol treatment.

There is definitely a physiological component to the cravings. Just as there is a physiological component to the "post-detox" withdrawals (when you're most likely to relapse) as the neurotransmitters in your brain flux and re-wire themselves. All of these are uncomfortable, but they also don't take the choice not to drink entirely out of your control.

AA is creepy, cultish, and completely Judeo-Christian (no matter WHAT they say about your "higher power".)

Substance abuse counselors, as a whole, are dicks. I'm of the opinion that the majority of them think that anyone who drinks *at all* is an alcoholic; the mantra being "you don't have to drink every day to be an alcoholic!" There is a rigid adherence to the traditional model of therapy & AA meetings; I went to one lady who basically told me that, after six months of self-achieved sobriety, I was on the verge of relapse because I had not gone through the traditional channels of therapy, et cetera.

The problem, I think, is that people are apt to falling back into old habits. Not even the drinking itself -- but surrounding yourself with your old drinking buddies, doing the same routine, returning to the same places. AA can help create new connections with sober people; but it also fosters a very black-or-white thinking with ideas like "falling off the wagon" or "one drink away from going back to what I was" whatever. Some people need this because they are unable to set boundaries for themselves. However, I am also a firm believer that *most* alcoholics can learn to set their own boundaries; relying on AA to set your boundaries for you is only harmful in the long run.

Check out Heavy Drinking: The Myth of Alcoholism as a Disease.

/has gone from drinking 1/2 pint hard liquor every night to drinking maybe once or twice a week. Without the accompanying cravings, thoughts , etc. It can be done. Quit telling me that it can't.

I'm a drunk who chose to quit drinking because I didn't want to kill an innocent person when I drove drunk. That was my impetus. AA has simply been a place where I can meet other success stories. I have also met many failure stories. If AA were only focused on sobriety, there'd be one step, stop drinking, instead of 12. I chose to drink, yes, but didn't choose to become an alcoholic--it's a progressive disorder and where the alcoholic often initially denies the problem once it has become obvious. Here's my inside info: those who focus on the psychological reasons behind drinking take a lot longer to get sober. Those who realize that alcohol physically impairs them from the first drink onward are more likely to be successful. It may not be a disease, it may be a matter of brain chemicals, but I don't care: I can't handle drinking any longer. I stopped and have seen others stop in AA. End of story.

Dear Anon Med Student, OMG! You are going to have a horrible awakening next year when you go "clinical" unless, of course, you are going into Psychiatry,or maybe Rehab, where it is to your benefit to have addiction labeled as a disease..Yes it is all about getting re-imbursed for a "disease" as you really can't get insurance to pay for a bad choice now can you? (see DSM)Come visit after your 3rd year. You'll be singing a different tune..

And another thing. This "detox" BS. I've been doing this doctor gig for 30 yrs now and I have yet to see any alcoholic die(or any addict) from withdrawal alone and I dare anyone to show me a case of "death by withdrawal" on a death certificate, period.

i have never heard or read about the lack or mortality from ethanol withdrawal, quite the contrary, the mechanism always usually stated as status epilepticus from etoh w/d and hyperthermia from d/t's rhabdo etc...

come to think of it though, in one of the heaviest drinking cities in the country i saw plenty of AKA, etho w/d sz, severe etoh w/d etc... and never witnessed a death in said patients.

one of the old guys mentioned the old literature which seemed to support beta blocker therapy alone for etoh w/d...

had a very confusing case, 22yo with chest pain... twenty two, with chest pain. his heart rate went from 110 when he got to us to 160 with ivf and pain control. i looked everywhere including his lungs for a source of his presentation and only after the guy had started to hallucinate did the oncoming resident walk into the room after hearing my confused presentation and say, 'this guy's in withdrawal'.

turns out at 22 he was in the bottle up to 2/5 a day and did go cold-turkey about 12 hours prior to his presentation. his body didn't like it very much and two of ativan made him look like a freaking athlete. duh.

I know we were all taught that DT's were lethal. Well I'm challenging that with 30 yrs experience plus your 7 or 8. Again, has anyone of us practioners of medicine actually seen a death from Withdrawal Sx? Has anyone seen staus epilepticus from alcohol withdrawal alone? No, they have 20-30 sec seizures and almost always stop before we can get the ativan in them! If they have rhabdo, it's because they were so drunk they laid on the floor for 19 hours not moving, not because of sz!

E, have you seen a death you can say unequivocally it came from withdrawal alone in your, uh, quiet population??

a ph of 6.9 could be from alcoholic ketoacidosis or from rhabdomyolysis or from acute severe ethanol/methanol/ehylene clycol/aspirin, or from acute renal failure, or from isoniazid toxicity, or etc.... to simmply say that "his ph was 6.9 from withdrawal" is assuming your diagnosis AND the diagnosis of 'withdrawal' is not a lab diagnosis. besides, you said he 'nearly died'... the question remains.

From what we've been told (for hundreds of thousands of dollars) is that it's the Status Epilepticus that's the lethal portion of the DT's. 3 days of tapering doses of the medium-acting Benzo du-jour and your alchie is on his/her way out the door and back to the packie. I've never seen the DT's, but then again I'm a second year med student with about 6 weeks ED time.

A little bit off topic, but if we're going to stop calling poor life choices diseases, can we please stop calling obesity a disease? Otherwise we're going to have to cure my girlfriend's sister's unplanned pregnancy by her probation-violating, child-support-evading boyfriend. But that's only after her father finishes curing her choice to date him with some Italian-made cement-shoes someplace out in the Harbor...

3rd year FP rotation I spent with a GP in a small southern town. He always had several patients in the hospital for "detox", all alcoholics. The cool thing was he had them on IV ethanol for the first few days then changed them over to po librium. Thats the only place I've ever heard of IV ethanol.

I think the best example of the disease as crutch model is best seen in liberal jackass Hollywood. Just once, instead of running of to "rehab" I'd like to see one of the Baldwin boys or any other F.A.G. (film actors guild) member say " You know, I enjoyed that coke alot. My body felt great, and I thought I could fly. But this neck brace and charge of involutary manslaughter have made me realize it wasn't the best CHOICE! " AMEN brother.

911, good on ya with the Britney reference! I'm a Winona Ryder man myself. Can't wait for the "StarTrek" movie next year, I think shes playin a Vulcan chick. Really, I've got some 25 DVD of the movies shes been in. My wife thinks its a little strange, but atleast I dont gamble or chase other women. The best was when she agreed to go to a Halloween party with me as Edward Scissorshands and her as the winona ryder part. You owe it to yourself to check out Brits movie "Crossroads" from a few years ago. Its total crap except for 45 seconds of her dancing on her bed. That'll take away anyones suicidal ideations.

On another topic, I've always hated prescribing sleep medications. Even the supposedly non addictive ones end up being abused, and I'm convinced people should do it my way. 100 pushups and jackoff. Its worked since I was 12, OK so I ended up needing glasses, but I've got great upper body strength and no 12 step meetings to go to. Try suggesting that to a patient though(I leave off the jacking off part). They look at you like you suggested exorcism or something.

EE, some guys have cabinets full of porn, I have a rack full of "Little Women","Heathers", "Mermaids" "Girl Interrupted(Double Bonus, includes Angelina Jolie)" I did pass on the one she did with Adam Sandler.

Here is something funny that I don't want to post on my own blog (what if my mom read it?!?), but you will probably laugh about it here since we are talking about porn.

Back stuff to make this make sense. 1. We have this glass heart thing that the kids hide under each others pillows and each night a different person gets it. The trick is you have to be sneaky and hide it without anyone knowing you were the one to hide it. So the part that is relevant to this story is that each night everyone in our house flips over their pillow to see if they are the one with the heart that night.

2. When we watch Lost, the kids have to be in bed and I told them that Lost is a show for grown ups only because it is too scary.

Now the funny-ish story. For valentines day, I wrapped up a movie for my husband and put it under his pillow. I thought the kids were all in bed already. One of them flipped over his pillow and saw the present. When they asked what it was, I said it was a movie that kids can't watch. My youngest said "like Lost?" which was a great cover for what it really was so I went with that. The results could have been disastrous so I was happy to have them think that!

EE, no, I'm a 40s doctor man, but I'm sure your fiance is a genius and will have a stellar career. He's already shown his smarts by goin the PA route, Med school and residency just delay your adolesence. And just a note, its "Winona" we like, the hot one who shoplifts. "Wynona" is the ugly Judd sister with an alcohol problem. Ashley Judd is Ok though.

Two hundred male and female patients, selected at random from all patients admitted to an inpatient alcoholism treatment facility in 1973–1974, were surveyed 10 years following treatment. Response rate was 80%, and a validity check was done. Of the 158 usable responses, 61% reported complete or stable remission of their alcoholism for at least 3 years prior to the survey and 84% reported stable psychosocial status. Successful outcome was possible regardless of severity of drinking history or psychosocial status. Seventy-six percent (76%) of those still alive at follow-up reported remission; at most, 23% of the deceased were reported in remission prior to death. Involvement in Alcoholics Anonymous (AA) predicted abstinence, suggesting successful outcome for patients who undergo a treatment regimen, which bridges patients into AA involvement. Of those respondents who continued to sponsor other AA members throughout the follow-up period, 91% were in remission at the time of survey.

dear anonymous. i really will try to be nice here but 1990? a retrospective survey? a survey incredibly biased by the mere fact that there is no placebo arm, no control, and a preselection bias of those admitted to inpatient alcohol reahbilitation? if one accepts that there is such a thing as 'good research' then there is a thing called 'bad research'. this is a book report, not even a placebo controlled study, much less the gold standard for allopathic medicine, which is a double blind, placebo-cotrolled study. and just so you know, no hard feelings and all, i really wish observational research was worth a damn, then MDOD would be a medical reference. try again.

"Just for fun try to find the 5 year success rates, published, from reputable journals, on the success of our current treatment of ''addiction as a disease''. You probably can't and there's a reason. The success rates are no better than going "cold turkey". It's about 5%."

I see how this works now. You ignore your previous statements and change the rules to raise the bar. That study addresses your question.

BTW-Do you generally refuse to use any medical treatment that is not supported by a double blind, placebo-controlled study, or just with populations you hate?

no rule changes, i asked for you to produce the "definitive study" and what you produced was, as i said, not even really a study, it was, in fact, a book report based on interviews of the subjects themselves.

no. i do not refuse to use therapy not based on double-blind placebo controlled studies though we try to advance our knowledge by this means. some things are impossible or unethical to study in this way. for instance, we can't create a control arm or a placebo arm for people with appendicitis as the death rate would approach 100%. we know how to fix appendicitis... 99%of people who get appendectomies walk out of the hospital, probably 10% or so survived prior to surgery.

also, the framingham study on heart disease (i may be wrong about the name, it may have been a related study) was stopped two years-in as the folks in the placebo arm were dying at much higher rates than the ones receiving an aspririn a day. this demonstrates the power of these large, blinded studies. the docs administering the meds had no idea, the guys crunching the numbers figured it out.

designing a double blind placebo controlled study for addiction treatment would be easy and wouldn't cost a lot. one arm, cold turkey, one arm, twelve step program, one arm, brief behavioral modification counselling, one arm, tapering benzo doses with counselling etc... that's the kind of study that would convince me, one where the 12 step "addiction as a disease" model was clearly superior to the other choices. at this point i do not believe that these studies have not been done, but that the data does not support the boatloads of cash sent to the twelve step programs.

There was some English soccer player who died from cirrhosis a few years ago. After countless relapses, he had some kind of disulfiram coated device implanted in his stomach. Don't know if he stopped drinking but it sounds pretty cool. If you look at who actually attends AA or NA, probably 50% are there under court order for DUI or other offences and have no intention of becoming sober once their quota of meetings is done.

About the "disease" model. I don't understand why we apply it to alcohol or meth, but not nicotine. The regimen for nicotine cessation is replacement. Chantix, which people seem to love, doesn't require immediate cessation.

There's a multimonth step down program for the gum, patch, and lozenges.

This is every bit as unhealthy, dangerous, and detrimental, but we don't apply the AA or NA logic to this. Why?

If quitting smoking or chew involves replacing your nicotine in a controlled fashion, why does this not continuously reawaken the supposed demon out of control?

I am but one person, but I quit using chew after 10 years of fairly heavy use. It fucking blows. But I tried the just outright quitting thing and it's hard. With NRT, I had significantly less withdrawl and difficulty in mainting nicotine free habits.

It would be a very bad idea to try some chew again, but I know I could smoke a cigar, pipe, or cigarette right now and not be out buying a can a day of chew.

I don't see the validity in this disease model. Part of the breakdown in the disease model is that when you get a disease, you suffer and then develop and immunity. How the fuck is a life of AA an immunity for anything?

traditional teaching that i agree with is this (oldfart has made a challenge as you can read above which has not been answered yet).

addiction is an emergency sometimes because people get shot or stabbed or overdosed because of their abuse of substances. otherwise it is an emergency when the 'addict' becomes suicidal.

withdrawal is another matter. traditional teaching is that severe alcohol withdrawal can kill you and that benzodiazepine (valium and the like) withdrawal can kill you, both through similar mechanisms.

heroin and opiate withdrawal is unpleasant but not medically dangerous. you get flu like symptoms and start jonesin' for a fix.

yeah, i'm thinking about the guy who re-presents within two days after getting off a nac infusion with ... drum roll ... another paracetamol overdose because of x y z. the words "external locus of control" was used like an insult in case meetings.

no discussion of axis II vs. mental illness. i'm staying wayyyy away from that. i don't have your brass balls, 911doc, but i'd like to know where to get some. ebay?

I live in a small town,population less than 15,000.The biggest news around town these days is this. Three very young people died, within an eight hour period. All three died from a combination of methadone, lortab, and xanax. All three had prescriptions, from a well known local physician.He and two other physicians are now under investigation, for a large number of such deaths, in the last year.

That is only the beginning. The mayor has said the city is declaring war on physicians, who abuse the privilege to prescribe drugs. One person had a bottle, which had contained 360 pills. The bottle was almost empty. One of these docs attempted to throw the sheriff, who was asking questions, out of his office.

Only one physician has actually been identified, but everyone knows who the others are.Many addicts are enabled by their doctors. It's true enough they are not taking responsibility for themselves, but these doctors should know better.

Believe me these prescriptions were not forged. I am acquainted with a person, who received 120 lortabs, and 120 xanex every month, from this physician. She paid for them herself, because her insurance only covered a certain amount. He was only in the office three days a week. On those days his waiting room was overflowing.

This young lady, I am referring to is rather unstable. Allowing a person like her, such easy access to pain medication is inviting disaster. Fortunately it didn't happen to her, and she is now getting help. Others were not so lucky.

I believe the majority of doctors are doing the best job they can. I have complete trust in my own doctor, but then again, I have never been seriously ill.

A person is ultimately responsible for their own behavior, but everyone, including doctors, should refuse to enable them.

Mmmf. I'm in recovery, went the AA route, and it's been a little over 12 years now.

I don't believe that there is *any* one panacea to addiction/alcoholism, and have my wee doubts that the AA 12-step model applies well outside the specific arena of alcohol addiction.

Just as in the halls of medicine, in the halls of AA exist the "book nazi's" who believe themselves blessed of the one true path. In each case, I find them about as beneficial as tits on a bull.

I've seen AA help a lot of folks, and I've seen plenty of folks it didn't help. There seemed to be more in the second group that were court-ordered or were otherwise trying to please someone else, rather than fix themselves for their own reasons.

I found it particularly helpful in early sobriety, both the success stories (a hint that, gee whiz, there WAS hope and all need not be gloom and doom) and the failures (bad examples can be motivating, too - kinda "oooh, that doesn't look at all fun").

But just like penicillin isn't a panacea for all bacterial badness, the 12 steps aren't the answer for all addictive badness, and certainly not for underlying mental illness.

Just want to point out, mental illness is not detectable by any lab test, if it were detectable it would then become subject to neurology ( I think). It is peoples non-physical minds psychiatrists are attempting to fix with psychiatric meds/drugs.

Addiction starts out as a choice, but we all know it usually turns into a physical dependancy as well.

The word "Addiction" is debatable as well, if you are earning an income doing your job well and using whatever drug reasonably, is it addiction? Its only when the persons life goes in the toilet is it called an addiction.

That being said, the sane and insane are resposible for their actions. Both have reasons for their actions, not devils or magical chemical imbalances making them perform complicates actions such as finding , paying for and consuming drugs.

dear anonymous, you had me till the last sentence. the truly insane are legally not responsible for their actions. the legal theory is based on medical evidence though it did develop before the science was there. but acutely decompensated schizophrenic patients actaully can not distinguish reality from non reality so i they are not, again, legally or medically, responsible for their actions. cheers.

"but acutely decompensated schizophrenic patients actaully can not distinguish reality from non reality so i they are not, again, legally or medically, responsible for their actions."

Legally ,yes of course you are correct. I never heard it referred to as "medically" responsible.

I was talking common sense, if you can do the 101 things to get to point A to do action B and C, you must be reasoning fairly well,(or you would not reach your goals) therefore must be sane. This is from an unmedicated diagnosed paranoid schizophrenic.

I came across your blog through a friend and have been enjoying the discussion. I really don't have any experience with alcohol addiction/AA so I won't try and act like I do. I tend to think addiction is a choice to an extent. If I choose to snort cocaine and keep doing it, that is a choice. My situation is a little different though. I have a "mental illness" if you will. I have suffered from anxiety and panic attacks for 13 years now. I did not choose for me to feel this way. I was rather young and naive then and when I went to the doctor, he put me on an anti-depressant and a benzo. I didn't realize at the time that they were so addictive (Ativan) and that they shouldn't have been prescribed for a long period of time. So here I am 13 years later addicted to them. I do not abuse them or take more than I need, but I cannot skip a dose or I go into major withdraw. What ticks me off the most is that my psychiatrist should have known better. I find myself constantly worrying that if I take one "as needed" I may find myself really needing that extra one on a daily basis. It would be so very easy for me to just take another one to get the edge off, but my fear of addiction is too strong. That is where I make my choice. I find it ironic that my psychiatrist tells me so freely, to take another Ativan whenever I feel anxious, and I am the one fighting it for all I am worth.

Is it addiction? Most likely. Was it a choice? I don't know.

Oh, and Mark, it may not be able to be detected by a blood test yet, but by no means does it make it non-physical. If it is not a chemical inbalance, what exactly is it? Is it all in my head? I have had my share of crappy psychiatrists and experiences that are way too numerous to tell right now, and that is why I ended up going back to my family doctor. If it is not physical, why have so many people been helped by medication? It is all trial and error, granted, but many people have been helped by medication.

Now that I've rattled on forever, I will humbly crawl back in my hole.

benzos are a bitch to quit. you are mostly correct that they should not be prescribed long term but it is quite common for the simple fact that they work. i would suggest to you that a large part of your problem now is that your brain believes you are addicted. if you are taking small doses of ativan, i.e. 2-3 mg per day, then physically speaking, getting off of them should be no problem. the mental part is harder. cheers, j

Right now my psychiatrist has me weening off effexor. I could kill the man for putting me on that! He said to just ween off one pill a week and I went psycho.....literally! And then when I saw him, he said "Oh yeah, some people do have a hard time coming off that."

Ya think? It would have been nice to have been told. He's a real winner, for sure. I finally went back to my family doctor.

the problem with effexor is that, unlike the other SSRIs (celexa, lexapro etc...) it has a short half life. ativan, a benzodiazepine, is a different drug entirely but also has a short half life. the consequence of the short half-life (the amount of time it takes your body to process 1/2 of the dose and eliminate it) is that the medicine works quickly, contrarily, when you stop it your body DOES notice. ssri's were not thought to have withdrawal syndromes related to them but this has proved to be false. wanting to stay away from medical advice on this site i would still offer this, suggest to your family doctor putting you on an ssri that has a longer half life and transitioning you off of ativan to a benzo with a longer half life and tapering you to nothing. good luck.

mark, as you know there are extremes of your disease. you, obviously, are doing quite well. if you have ever been admitted for schizophrenia and been in a very strange place with the voices pounding in and unable to distinguish them from real voices then you know what i mean.

i do not disagree that choices that folks make probably impact their development of schizophrenia as cocaine and crystal meth and amphetamine abuse can create a mental state indistinguishable from schizophrenia.

also, identical twins have only a 50% concordance of schizophrenia so there's more to it than genetics.

congratulations on managing your problem without medicines and good luck to you sir.

dang...again, i agree wholeheartedly. i work with people....all of whom have been taught/indoctrinated that they have no control over addiction/behavior/attitude...& that they are continually the victim.

it's just nice to see there are others in this world wanting to do their work well that are fed up with how things are working these days.